High acceptance of HIV self-test kit among Nigerians but accessibility, lack of awareness pose major barrier

The first time Sophia Daniel, a sex worker, did an HIV test, it was from the comfort of her rented apartment in Suleja, a city in Niger state, Nigeria.

Ms Daniel had stopped by a pharmacy a day before to purchase the HIV self-test kit following what she described as “an enlightening conversation” with her colleague. She said the pharmacist explained the process of using the test kit to first check her status after which she could visit a health facility for confirmation.

Four days after purchasing the kit, Ms Daniel summoned the courage to know her status. “The result was positive, I couldn’t believe my eyes. I cried all night,” she said.

At dawn, she visited a health facility far away from her home to confirm the diagnosis. “It was confirmed, I’m HIV positive,” she said.

Ms Daniel said although she is unhappy about her status, having the self-test kit to first confirm her status was a saving grace as no one in her community is aware of her status.

“I have always wanted to know my HIV status due to the risky nature of my job, but I was always scared of the way people judge sex workers, especially when they see you visiting the hospital or laboratory,” she said.

Many others like Ms Daniel, whose name has been changed for privacy reasons, are embracing HIV self-testing majorly because it protects one from the sting of discrimination and other factors linked to HIV.

For Malik, a civil servant residing in Kubwa, a suburb of Nigeria’s capital city, Abuja, the HIV self-test kit is one of the best health innovations ever. He said he first heard of the kit from his family doctor.

“I was discussing with our family doctor when he mentioned the HIV self-test kit and how easy the process is,” he said.

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Mr Malik said afterwards, he decided to get the kit to confirm his HIV status. “I did and the result was negative. I think it is the best health intervention because patients get to avoid the hassles at Nigeria’s health facilities,” he said.

HIV self-testing

Before now, HIV testing in Nigeria and other parts of the world was only provided at health facilities and through population screening efforts such as free HIV testing campaigns and other programmes.

Although this has increased access to and brought about an uptake of HIV testing services over the past decade, a significant proportion of people at high risk still do not know their status.

Despite the scale-up in testing services, many adolescent girls and young women, and the key populations; men who have sex with men, transgender people, sex workers, people who inject drugs, and people in prison, are still left behind.

Asides from vulnerable groups, many people are usually skeptical about undergoing an HIV test. This is mostly because people are afraid of being stigmatised by health workers and other patients if the result turns out positive.

For countries to reach the United Nations 95-95-95 targets for 2030 – the first of which is diagnosing 95 per cent of all people with HIV, people like Ms Daniel must have access to HIV testing services.

This and many other challenges prompted the World Health Organisation (WHO) to recommend the HIV Self-Testing (HIVST) option that can be used to reach undiagnosed populations.

HIVST is a process in which a person collects his or her sample (saliva or blood) using a simple rapid test to ascertain their HIV status privately and at their convenience. With the self-test kit, people can know their HIV status within 20 minutes.

The Project Director, Unitaid-funded HIV Self-Testing in Africa (STAR) project, Victor Adepoju , said the self-test kit was developed to address barriers to HIV testing.

Mr Adepoju said it also empowers individuals to test themselves for HIV from the comfort of their homes or in a confidential environment.

Achieving target

As part of efforts to achieve the first 95 per cent of the United Nation’s target, many countries have adopted and are implementing HIVST policies.

According to the WHO, the number of countries with supportive HIVST policies grew nearly 13-fold, from six countries to 77 between 2015 and 2019.

Data also shows that the number of countries implementing HIVST nearly tripled from 14 to 38 between 2017 and 2019. The majority of those implementing the policies are in European and African regions, of which Nigeria is one of them.

Although Nigeria, a country with about 1.9 million people living with HIV approved the use of the self-test kit in 2019, it wasn’t in circulation until late 2020.

In an interview with PREMIUM TIMES, the director general of the National Agency for the Control of AIDS (NACA), Gambo Aliyu, said the self-testing policy was introduced to empower people to take charge of knowing their HIV status.

Mr Aliyu noted that some people wish to know their status but are unwilling to visit health facilities due to fears attached to testing positive for the virus.

“With self-testing, an individual can know their status within a private space and decide on how to control the information.”

He said with this new approach more and more persons will get tested and “we can close the gap in the first 95 per cent target of UNAIDS.”

Mr Aliyu, however, said until HIV testing reaches the key population like Ms Daniel, the country may not meet the 2030 target.

He said globally, key populations face much higher rates of HIV/AIDS than the general population and are most at risk for contracting the virus.

The UNAIDS estimates that between 40 per cent and 50 per cent of all new HIV infections may occur between individuals in key populations and their immediate partners.

In Nigeria, sex workers, men who have sex with men, and people who inject drugs make up only 3.4 per cent of the population, yet they account for about 32 per cent of new infections.

“With this innovation, key populations and others who lack access to HIV testing services can know their status and commence treatment,” he said.

Breaking stigma, discrimination barriers

Health experts said barriers like stigmatisation, long queues at health facilities, distance to facilities amongst others are restricting people from knowing their HIV status.

Mr Adepoju, the Project Director, Unitaid-funded HIV STAR project, said the HIVST was introduced to address some of the barriers to testing services. He said due to stigmatisation, key populations like sex workers and others are unwilling to visit health facilities for testing.

He said the test kits also help the Adolescent and Young People (AYP) who don’t like visiting health facilities to know their status. He said various studies show that these groups like to patronise pharmacies or adolescent-focused health centres.

“We believe that this innovation will help the country close the HIV testing gap,” he said.

Mr Aliyu, the NACA boss, said with the self test kit, people can know their HIV status without fear of rejection or stigmatisation.

“When you test yourself personally and realise you have HIV, you have removed a lot of people from the equation. At this point, you can contact someone you trust or a health facility you feel comfortable with to access HIV services,” he said.

Acceptability

For years, the idea of testing for HIV from the comfort of one’s home and without a health professional sparked concerns that it might put people who test positive at risk of depression which could lead to suicide. But various researches have shown that the privacy and convenience of using the home test kits plays the trick in self-testing.

A vox pop carried out by PREMIUM TIMES to ascertain the level of self-testing acceptability shows that many people for various reasons chose this option over visiting a health facility/laboratory for testing.

Tajudeen Alawode, a resident of Lagos State, said the self-test is a great innovation as it helps one know their status from the comfort of their private space. He said the innovation will also encourage people who feel reluctant visiting the health facility to know their status.

“The self test kit is a very good improvement because knowing one’s HIV status makes one feel safe,” he said.

Ella Joseph, a resident of Masaka, a town in Nasarawa State, said she was willing to spend all her allowances on the self-test kits if only to avoid contact with health workers.

Similarly, Daniel Ochuma, a fashion designer in Abuja, said the privacy and convenience of using a self-test kit is the highlight of the innovation. Mr Ochuma said although he has never seen one, he is willing to use it if available.

Ita Abia, a resident of Akwa Ibom State, said he has used the self test kit and would recommend it to others. Mr Abia said those afraid of visiting a health facility due to stigma and other factors can use the self-test kits to ascertain their status.

Accessing test Kit

A major challenge with the use of the HIV self-test kit is accessibility. A survey carried out by PREMIUM TIMES in Abuja, Niger, Kwara, Lagos, and Nasarawa states indicates the unavailability of the kits in most pharmacies. The kits were only found in a few top pharmacies within the aforementioned states in the country. Out of 62 pharmacies visited, only 11 had at least one of the various types of test kits.

Ms Daniel, the sex worker in Suleja, said she couldn’t find the test kit within her environment. “I had to buy somewhere around Asokoro within Abuja city,” she said.

Without easy access to the test kits, many people will be discouraged from knowing their status. A pharmacist, Rose Benjamin, said most medicine stores do not stock the HIV self-test kits due to low patronage.

Ms Benjamin said people only make enquiries about the kit once in six months or even a year. “The truth is what people are unaware of, they cannot use. Many people don’t know the self test kits exist,” she said.

She noted that until there is an increase in demand, the probability of finding the kits in most pharmacies is very low.

Mr Aliyu, NACA DG, said efforts are ongoing to ensure the presence of the self-test kits in pharmacies and private hospitals.

He said for now, “we give the self-test kit free to certain population groups that are at greater risk of having HIV.”

He, however, said to ensure accessibility, various manufacturers are planning to make the kits available at pharmacies and private hospitals where people can easily demand them.

At some of the pharmacies visited, a pack of the OraQuick self-test kit costs between N1,150 and N1,300, a low amount compared to what is obtainable when one visits a laboratory for an HIV test.

OraQuick, which is the most common HIV self-test kit in the county, requires the use of oral fluid to carry out the test. The home test kits named Dr.Greg’s require the use of blood and its cost ranges from N3,900 and N4,600 depending on the pharmacy and location.

Mr Adepoju said the cost of a test kit is relatively high and efforts are in place to subsidise it. He said Unitaid has done a lot by adopting the subsidy approach to be able to scale down the cost.

“We have people at the community level that go around sensitising them and distribute vouchers that can be used to access the kits at cheaper rates. The demand has increased since we subsidised the cost. People are getting interested in using the kits,” he said.

Poor awareness level

At least 70 per cent of persons who spoke with PREMIUM TIMES have never heard of HIVST. “This is my first time hearing about the self-test kit but I will try it,” Elizabeth Bassey told this newspaper.

Mr Adepoju said awareness creation is key to increasing demand and use of the HIV test kit. He said without increased awareness, the majority of people will miss out on knowing their status, thereby failing to halt spread of the virus.

He said, if Nigeria has a lot of volume guarantee, that will give any negotiator the leverage to get a lower price because the volume is there.

“So we need to work around demand creation and make a lot of Nigerians aware of this product which will give us leverage to negotiate with manufacturers,” he said.

For Nigeria to diagnose at least 95 per cent of the people by 2030, there is a need for increased awareness of available HIV testing services, especially for the key populations.

The UNAIDS Country Director, Leo Zekeng, said that information about HIV testing, prevention, and treatment services must reach everyone, especially the key populations.

Mr Zekeng at a recent conference said the key populations are missing out on new HIV interventions due to various government policies. “There is a need for a reform of policies restricting key populations from accessing health services,” he said.